Provider Demographics
NPI:1366656167
Name:HERNANDEZ, JESUS
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 CALLE MATTEI LLUBERAS
Mailing Address - Street 2:
Mailing Address - City:YAUCO
Mailing Address - State:PR
Mailing Address - Zip Code:00698-3635
Mailing Address - Country:US
Mailing Address - Phone:787-856-2626
Mailing Address - Fax:787-856-2762
Practice Address - Street 1:40 CALLE MATTEI LLUBERAS
Practice Address - Street 2:
Practice Address - City:YAUCO
Practice Address - State:PR
Practice Address - Zip Code:00698-3635
Practice Address - Country:US
Practice Address - Phone:787-856-2626
Practice Address - Fax:787-856-2762
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR457291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR7680019OtherHUMANA HEALTH PLAN
PR30300OtherSSS SERV SALUD
PR7680019OtherHUMANA HEALTH PLAN